Anyone who knows any physicians in practice these days knows that doctors are feeling pressured on all sides, as their organizations implement and optimize electronic health records (EHRs), move forward to comply with the meaningful use requirements under the Health Information Technology for Economic and Clinical Health (HITECH) Act, prepare to transition to the new ICD-10 coding system, and fulfi ll diverse requirements related to the mandatory and voluntary programs under the Aff ordable Care Act (ACA). Indeed, for many doctors, it all feels like too much, and physician documentation is front and center when it comes to what’s frustrating them on a moment-to-moment basis.
It feels like a perfect storm, doesn’t it? Already-time-pressured physicians feel pushed to satisfy numerous different types of requirements. Given that many are already impatient with documenting within the physician documentation systems embedded in EHRs, those doctors, who often have received only minimal training in electronic documentation, create messy progress notes, using the copy-and-paste and copy-and-forward capabilities within EHR systems that readily enable “note bloat,” with the equivalent of many pages of paper notes ballooning across computer screens nationwide.
Yet CMIOs, CIOs, and others say that a combination of lack of good training and organizational discipline, confusion over increased documentation requirements, and a dose of urban legend are leading to the false belief on the part of practicing physicians that note bloat is inevitable. Instead, the industry leaders are helping doctors to rethink how and why they document, with sometimes startlingly effective results. And CMIOs are at the center of progress in this area.
“There’s a lot that we can do in how we structure notes in the EHR; it’s all too easy to pull a ton of information into the daily progress note, and a lot of that is not needed,” says Brian Patty, M.D., vice president and CMIO at the four-hospital, 650-bed HealthEast Health System, based in St. Paul, Minn. “Just training physicians to structure their notes to be more succinct helps.” What’s more, Patty says, “What I really tell physicians is, if your note isn’t viewable on a single screen. We’re trying to get them to provide more pertinent information; and we spend a lot of time designing our notes.” Patty and his CMIO colleagues at progressive patient care organizations nationwide are in fact beginning to take action to reform physician documentation for the new healthcare.
Pushing for note reform in Pittsburgh
One organization in which the push towards MD documentation reform is already far along is the 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system in Pittsburgh. “You have to socialize this,” says G. Daniel Martich, M.D., vice president and CMIO of UPMC, referring to the physician training he and his colleagues are doing these days. Indeed, Martich and several colleagues in IT, clinical informatics, and executive leadership in the organization began a complex process about a year ago, by first surveying thousands of doctors in the organization on their perceptions of physician documentation, and then gathering doctors together in two initial groups for activity, the first one being cardiologists.
“We went through every aspect of the note,” Martich reports. “What should be in it? What can be copied and forwarded? What shouldn’t be? We began with an in-depth discussion of the SOAP [subjective, objective, assessment and plan] format that every doctor was taught in medical school, and a discussion of how you write a progress note. And we said, “SOAP ‘2.0’ stands for ‘succinct and specific, original, accurate, and problem-oriented.’ For example, the ‘original’ part of that refers to the fact that if I’m an orthopod, I shouldn’t be copying the infectious disease doctor’s note; ‘accurate’ means that you’ve got to be proofing what you’re writing; and ‘problem-oriented’ means that we need to understand the patient by their illness.”
The first group of physicians who got involved in a first pilot in this initiative was a group of 40 attending cardiologists who, led by two cardiologists who were documentation reform champions, used classroom training and discussion to create a new kind of note in cardiology, which they called the “HVI progress note,” for “heart and vascular progress note.” The first pilot took place between October and November of 2013, and was followed up by reform work on consult notes, history-and-physical notes, and a reformed discharge summary. “Until the end of February,” Martich notes, “we were only in cardiology; but we said, gosh, it’s working so well there that we’re going to be taking the pilot to our trauma surgeons.”
The impetus for all this was very straightforward, Martich says. “We in the IT world have gotten to the point where we’ve pushed doctors to use tools, but now, it’s time for CMIOs to circle back and optimize and get them not to do ‘copy and paste and sloppy and waste’; instead,” he stresses, “you should be doing ‘SOAP 2.0,’ which means half-page-long notes, because no one’s reading your 20-page note. And because you’re not lumping in the lab tests or meds you ordered, since all that information can be found in the electronic record, right? You actually can get to the heart of the matter, and get [information to be] extractable and usable.”
From SOAP to APSO